11
Table 7. Dose Selection of Oral Anticoagulant Options for
Patients with Nonvalvular AF and CKD (Based on
Prescribing Information for the United States)
a
Renal
Function Warfarin Dabigatran
b
Rivaroxaban
b
Apixaban
b
Normal/
Mild
Impairment
Dose adjusted
for INR 2.0-3.0
150 mg BID
(CrCl >30
mL/min)
20 mg QD
with the
evening meal
(CrCl >50
mL/min)
5.0 or 2.5 mg
BID
c
Moderate
Impairment
Dose adjusted
for INR 2.0-3.0
150 mg BID
(CrCl >30
mL/min)
15 mg QD
with the
evening meal
(CrCl 30-50
mL/min)
5.0 or 2.5 mg
BID
c
Severe
Impairment
Dose adjusted
for INR 2.0-3.0
d
75 mg BID
e
(CrCl 15-30
mL/min)
15 mg QD
with the
evening meal
(CrCl 15-30
mL/min)
No
recommendation
f
End-Stage
CKD Not
on Dialysis
Dose adjusted
for INR 2.0-3.0
d
Not
recommended
f
(CrCl <15
mL/min)
Not
recommended
f
(CrCl <15
mL/min)
No
recommendation
f
End-Stage
CKD on
Dialysis
Dose adjusted
for INR 2.0-3.0
d
Not
recommended
f
(CrCl <15
mL/min)
Not
recommended
f
(CrCl <15
mL/min)
No
recommendation
f, g
a
Renal function should be evaluated prior to initiation of direct thrombin or factor Xa inhibitors
and should be reevaluated when clinically indicated and at least annually. CrCl should be measured
using the Crocko-Gault method.
b
e concomitant use of P-glycoprotein inducers or inhibitors with dabigatran, or the concomitant
use of dual P-glycoprotein and strong CYP3A4 inducers or inhibitors with either rivaroxaban
or apixaban, particularly in the setting of CKD, may require dosing adjustment or avoidance of
concomitant drug use (see the FDA drug label at http://www.accessdata.fda.gov/drugsatfda_docs/
label/2014/202155s002lbl.pdf ).
c
Use apixaban 2.5 mg BID if any 2 patient characteristics present: Cr ≥ 1.5 mg/dL, ≥ 80 years of age,
body weight ≤ 60 kg. Apixaban is not recommended in patients with severe hepatic impairment.
d
Dose-adjusted warfarin has been used, but observational data regarding safety and efficacy are
conflicting.
e
Modeling studies suggest that dabigatran 75 mg BID might be safe for patients with
CrCl 15-30 mL/min, but this has not been validated in a prospective cohort. Some countries
outside the United States use 110 mg BID.
f
No published studies support a dose for this level of renal function.
g
In patients with end-stage CKD on stable hemodialysis, prescribing information indicates the use
of apixaban 5 mg BID with dose reduction to 2.5 mg BID if the patient is either ≥ 80 years of age
or body weight ≤ 60 kg.
